Successful management of massive digoxin overdose using DIGIFab and therapeutic plasma exchange: a case report

BACKGROUND

Despite the efficacy and safety of DIGIFab, it is relatively expensive and has limited availability. In addition, alternative interventions, such as therapeutic plasma exchange, may need to be considered in massive digoxin overdoses. Although few case reports describe its efficacy.

CASE PRESENTATION

We report a case of a 17-year-old white male patient brought by family members to our emergency department in Riyadh, Saudi Arabia. After intentionally ingesting 48 mg of digoxin tablets to commit suicide, the patient's initial digoxin serum level was 8.04 ng/mL. The patient was resuscitated in the emergency department. After admission to the intensive care unit, the patient underwent therapeutic plasma exchange, because of insufficient DIGIFab doses. Afterward, the serum digoxin levels drastically decreased, and his symptoms reverted. The patient was successfully managed and discharged 7 days after admission.

CONCLUSION

Despite insufficient evidence and a limited number of case reports describing the use of extracorporeal treatment in digoxin overdose, we noted the significant impact of therapeutic plasma exchange on our patient. However, therapeutic plasma exchange's use in routine treatment requires stronger evidence to confirm its benefits.

Impact of intraoperative therapeutic plasma exchange on bleeding in lung transplantation

BACKGROUND

Our program uses a desensitization protocol that includes intraoperative therapeutic plasma exchange (iTPE) for crossmatch-positive lung transplants, which improves access to lung transplant for sensitized candidates while mitigating immunologic risk. Although we have reported excellent outcomes for sensitized patients with the use of this protocol, concern for perioperative bleeding appears to have hindered broader adoption of it at other programs. We conducted a retrospective cohort study to quantify the impact of iTPE on perioperative bleeding in lung transplantation.

METHODS

All first-time lung transplant recipients from 2014 to 2019 who received iTPE were compared to those who did not. Multivariable logistic regression was used to determine the association between iTPE and large-volume perioperative transfusion requirements (≥5 packed red blood cell units within 24 hours of transplant start), adjusted for disease type, transplant type, and extracorporeal membrane oxygenation or cardiopulmonary bypass use. The incidence of hemothorax (requiring reoperation within 7 days of lung transplant) and 30-day posttransplant mortality were compared between the 2 groups using chi-square test.

RESULTS

One hundred forty-two patients (16%) received iTPE, and 755 patients (84%) did not. The mean number of perioperative pRBC transfusions was 4.2 among patients who received iTPE and 2.9 among patients who did not. iTPE was associated with increased odds of requiring large-volume perioperative transfusion (odds ratio 1.9; 95% confidence interval: 1.2-2.9, p-value = 0.007) but was not associated with an increased incidence of hemothorax (5% in both groups, p = 0.99) or 30-day posttransplant mortality (3.5% among patients who received iTPE vs 2.1% among patients who did not, p = 0.31).

CONCLUSIONS

This study demonstrates that the use of iTPE in lung transplantation may increase perioperative bleeding but not to a degree that impacts important posttransplant outcomes.

Therapeutic plasma exchange in refractory Susac's syndrome: A brief report

Susac's syndrome (SuS) is an autoimmune endotheliopathy that typically presents with the clinical triad of encephalopathy, hearing loss, and branch retinal artery occlusion. It has a wide range of possible presentations, and its pathogenesis remains uncertain. Fulminant and refractory cases are difficult to treat, and no standard treatment protocol has been established. However, therapeutic plasma exchange (TPE) has been described as an adjunctive therapy in several SuS cases. Herein we present a case of a 63-year-old male with debilitating encephalopathy and recent hearing and vision loss, who responded favorably to TPE. Given this and other published reports of plasma exchange therapy for SuS, treatment protocols should consider TPE in early stages of disease.

Evaluation of sleep and therapeutic education needs of military with PTSD

Sleep disorders in post-traumatic stress disorder (PTSD) are both diagnostic (nocturnal reliving) and prognostic. Poor sleep worsens the daytime symptomatology of PTSD and makes it resistant to treatment. However, no specific treatment is codified in France to treat these sleep disorders although sleep therapies (cognitive behavioural therapy for insomnia, psychoeducation and relaxation) have proven for years to be effective in treating insomnia. Therapeutic sessions can be part of a therapeutic patient education program, which is a model for the management of chronic pathologies. It allows for an improvement in a patient's quality of life and enhanced medication compliance. We therefore carried out an inventory of sleep disorders of patients with PTSD. First, we collected data by means of sleep diaries concerning the population's sleep disorders at home. Then we assessed the population's expectations and needs regarding its management of sleep, thanks to a semi-qualitative interview. The data from sleep diaries, which was consistent with the literature, showed that our patients suffered from severe sleep disorders that strongly impact their daily lives, with 87% of patients having an increased sleep onset latency, and 88% having nightmares. We observed a strong demand from patients for specific support for these symptoms, 91% expressing an interest in a TPE program targeting sleep disorders. Thanks to the data collected, the emerging themes for a future therapeutic patient education program targeting sleep disorders of soldiers with PTSD are: sleep hygiene; management of nocturnal awakenings, including nightmares; and psychotropic drugs.

Role of therapeutic plasma exchange as a desensitization therapy in human leukocyte antigen incompatible renal transplant patients: A single-center experience

OBJECTIVE

Despite an increase in the rate of successful live donor renal transplantation done annually, the number of potential recipients with acceptable donors is relegated to the ever-expanding cadaver-donor waiting list due to sensitization to human leukocyte antigen (HLA) antibodies. If not sufficiently suppressed, these preformed HLA antibodies can trigger antimicrobial resistance (AMR) and early graft loss. To ameliorate this situation, various desensitization treatments are administered to provide a survival benefit to highly sensitized patients.

METHOD

One hundred and six patients in the time frame of January 2017 to March 2019 were included in the study group. The desensitization protocol included therapeutic plasma exchange and administration of low-dose intravenous immunoglobulin (100 mg/kg per therapeutic plasma exchange (TPE) session) to highly sensitized patients (treatment group) who subsequently underwent renal transplantation after negative pre-transplant Centers for Disease Control and Prevention Luminex crossmatch (CDC/LumXM). We compared graft survival rates between the group undergoing desensitization (treatment group) and matched control group of patients that underwent HLA-compatible transplantation.

RESULTS

In the treatment group, Kaplan-Meier analysis estimates an average rate of patient graft survival of 95.2% at 3 years post-transplant, as compared with the rate of 86.9% in the same time frame for the control-matched group (p < 0.05 for both comparisons).

CONCLUSION

Desensitization treatment with TPE before live donor renal transplantation in the case of patients with HLA sensitization provides better survival benefits along with monitoring for donor-specific antibodies (DSAs) and other infections, rather than waiting for a compatible organ donor. The data lays out evidence that desensitization treatments can assist overcome HLA incompatibility barriers in live donor renal transplantation.

Synergistic effects of core-shell structured piperazine pyrophosphate microcapsules on fire safety and mechanical property in styrenic thermoplastic elastomer

In this study, core-shell structured piperazine pyrophosphate (PAPP) is designed to enhance the fire safety and mechanical property of styrenic thermoplastic elastomer (TPE) composites. The PAPP is microencapsulated with carbon nanotube modified melamine-formaldehyde resin to prepare core-shell structured flame retardants (MT@PAPP). Due to the excellent compatibility between the MT@PAPP and TPE matrix, the mechanical property of TPE/MT@PAPP is improved. Compared with TPE, the peak heat release rate and peak smoke production rate of TPE/MT@PAPP are decreased by 78.5% and 60.0%, respectively. Thus, the core-shell structured piperazine pyrophosphate microcapsule strategy provides an excellent approach to obtain high-performance TPE composites.

In vitro-in vivo wound healing efficacy of Tridax Procumbens extract loaded Carboxymethylcellulose film

In this work, Tridax Procumbens Extracts (TPE) were blended with Carboxymethylcellulose (CMC), and film was developed through the casting method. The phytochemical screening of the TPE/CMC film was carried out and found the presence of carbohydrates, tannins, saponins, and cardiac glycosides. The presence of elements such as C, O, Na, P, Cl, K, Ca, Mn, and Nb in TP/CMC film was confirmed through EDX. The melting point of the film was found around 291 ± 0.5 °C which was determined through the DSC curve. The maximum tensile strength of the TPE/CMC was found as 14 ± 0.5 MPa. The film showed antibacterial activity against Escherichia coli, Streptococcus pyogenes, Staphylococcus aureus, and Vibrio cholera compared to the control. Cell viability study exhibited 95 % and 98 % cell proliferation for the test film after interacting with the L929 cell line for 18 h and 24 h. The optical contact angle of the TPE/CMC film was also determined. The in-vivo, wound healing studies on adult mice showed healing within 10 days only and the histopathological results revealed the maximum number of fibroblasts with a high density of collagen fibers in the test group indicating that the prepared film can be an effective wound dressing material.

Plasmapheresis in the ICU

Therapeutic plasma exchange (TPE) is a treatment paradigm used to remove harmful molecules from the body. In short, it is a technique that employs a process that functions partially outside the body and involves the replacement of the patient's plasma. It has been used in the ICU for a number of different disease states, for some as a first-line treatment modality and for others as a type of salvage therapy. This paper provides a brief review of the principles, current applications, and potential future directions of TPE in critical care settings.

Efficacy of therapeutic plasma exchange in pediatric cases of acute liver failure as an extracorporeal liver support system

BACKGROUND

Acute liver failure in the pediatric population is often accompanied by deranged metabolism, severe encephalopathy and coagulopathy. A liver transplant is the most viable option for the management of such patients. Therapeutic plasma exchange (TPE) is helpful in improving the liver biochemistry profile, thereby, increasing their likelihood of undergoing a liver transplant METHOD: The study was conducted over a period of 3 years (January 2018 to December 2021). Indications mainly consisted of ALF with hepatic encephalopathy, worsening liver parameters in spite of medical management, and candidacy for undergoing a liver transplant. Plasma exchange was performed daily or alternatively until the patient recovered, succumbed, or was stable enough to undergo a transplant. Biochemical parameters serum bilirubin, ALT, AST serum ammonia serum urea, serum creatinine were recorded before and after TPE sessions.

RESULTS

The study group comprised 14 patients of which a total of 28 TPE was performed. There were a total of 5 cases of cryptogenic ALF, 4 of Wilson disease, 2 cases each of infection-related ALF and autoimmune hepatitis, and a single case of drug-induced hepatitis. A total of 5 out of 14 patients underwent a liver transplant and amongst the 9 who did not undergo a transplant, 4 patients expired due to septic shock syndrome; the remaining 5 were discharged in a stable condition following TPE sessions. The disease-free survival was 78.9% and the transplant-free survival was 35.71%.

CONCLUSION

TPE plays a crucial role in improving the biochemistry profile of the liver in children with liver failure.

Patient's learning needs and self-efficacy level after percutaneous coronary intervention: A descriptive study

AIMS AND OBJECTIVES

Identify and compare learning needs, levels of self-efficacy and their association among inpatients and outpatients of a cardiac care unit with coronary heart disease who have undergone percutaneous coronary intervention (PCI) in a Swiss university hospital.

BACKGROUND

After primary PCI, 42% of patients will suffer a recurrent ischemic cardiovascular event. Although adherence to therapeutic regimen contributes to prevent recurrence, patient adherence remains low. To strengthen it, learning needs and self-efficacy must be considered when developing effective therapeutic patient education (TPE).

METHODS

Learning needs and self-efficacy were assessed using the Cardiac Patient Learning Needs Inventory (CPLNI) and the Cardiac Self-Efficacy Scale among inpatients and outpatients. The STROBE checklist for cross-sectional studies was used in reporting this study.

RESULTS

Ninety-three patients participated in the study with a participation rate of 73.9%. The CPLNI median total score was significantly higher in inpatients than in outpatients: 4.23 (3.82, 4.64) versus 3.67 (3.33, 4.09), p < .001. In both units, participants declared that the most important need was related to 'anatomy and physiology' of the heart. Despite the high score, the least important need was about 'physical activity' for inpatients and 'miscellaneous information' for outpatients. No statistically significant differences were found among patients from both units regarding their self-efficacy level.

CONCLUSIONS

This study shows that after PCI, patients have high learning needs and moderate levels of self-efficacy that require addressing.

RELEVANCE TO CLINICAL PRACTICE

Patient's individual learning needs and self-efficacy level must be assessed prior/after PCI. A tailored TPE that considers individual learning needs and self-efficacy is recommended as a preventative measure to reduce recurrent ischemic cardiovascular events. Nurses can play a key role in this process.

NO PATIENT OR PUBLIC CONTRIBUTION

For feasibility reasons, patients and public were not involved in the design, conduct, reporting or dissemination plans of this research.

Therapeutic Plasma Exchange in Catastrophic Antiphospholipid Syndrome (CAPS): A Rare Case Report and Literature Review

BACKGROUND/AIM

Catastrophic antiphospholipid syndrome (CAPS) may be the first manifestation ("de novo") of antiphospholipid syndrome (APS) or a complication in the clinical course of patients known to have this syndrome. Approximately 40% of patients had an associated autoimmune disease, mainly, systemic lupus erythematosus (SLE). The trigger can be one of the following: infections, surgical interventions, neoplasms, pregnancy, discontinuation of anticoagulant treatment, and others. CAPS is a medical emergency in which early identification and prompt initiation of aggressive therapy is extremely important. According to the Guidelines for the use of Therapeutic Apheresis in Clinical Practice developed by the American Society for Apheresis (ASFA), last updated in April 2023, in CAPS, the indication for therapeutic plasma exchange (TPE) is category I, grade 2C.

CASE REPORT

We present a case of probable CAPS secondary to systemic lupus erythematosus (SLE) in an elderly patient in whom clinical and biological improvement was achieved through a multidisciplinary approach and prompt initiation of TPE. Because TPE is considered first-line therapy in CAPS, we initiated the procedure as soon as the attending rheumatologist raised this suspicion. Four plasmapheresis sessions were performed in the Intensive Care Unit. We used TPE by membrane filtration. Following the therapeutic intervention with TPE, corticotherapy (Solumedrol in puls-therapy), cyclophosphamide and anticoagulant treatment, the evolution was favourable, with clinical and biological improvement.

CONCLUSION

The prompt initiation of TPE, because of the suspicion of CAPS, increases the chances of a favourable evolution.

Cytokine Adsorption as an Adjunctive Treatment for Patients with Immune-Mediated Hemolytic Anemia Receiving Therapeutic Plasma Exchange: A Case Series of 3 Dogs

The use of cytokine adsorption is an emerging treatment for inflammatory diseases in human medicine. There are few reports of this treatment modality in veterinary medicine and no reports of the use of a cytokine adsorbent for immune-mediated hemolytic anemia (IMHA). These case reports illustrate the use of a cytokine adsorbent as an adjunctive treatment during therapeutic plasma exchange (TPE). All dogs were unresponsive to conventional treatment or were severely affected by rapid hemolysis of red blood cells. The aim was to treat all dogs with three sequential TPE sessions; however, one dog died before completion of three sessions and one dog required additional sessions. Preliminary evidence indicates that the use of a cytokine adsorption is well tolerated and can be considered as an adjunct in the management of IMHA that is severe or refractory to traditional treatment.

Synthesis and Characterization of Tetraphenylethene AIEgen-Based Push-Pull Chromophores for Photothermal Applications: Could the Cycloaddition-Retroelectrocyclization Click Reaction Make Any Molecule Photothermally Active?

Three new tetraphenylethene (TPE) push-pull chromophores exhibiting strong intramolecular charge transfer (ICT) are described. They were obtained via [2 + 2] cycloaddition-retroelectrocyclization (CA-RE) click reactions on an electron-rich alkyne-tetrafunctionalized TPE (TPE-alkyne) using both 1,1,2,2-tetracyanoethene (TCNE), 7,7,8,8-tetracyanoquinodimethane (TCNQ) and 2,3,5,6-tetrafluoro-7,7,8,8-tetracyanoquinodimethane (F₄-TCNQ) as electron-deficient alkenes. Only the starting TPE-alkyne displayed significant AIE behavior, whereas for TPE-TCNE, a faint effect was observed, and for TPE-TCNQ and TPE-F₄-TCNQ, no fluorescence was observed in any conditions. The main ICT bands that dominate the UV-Visible absorption spectra underwent a pronounced red-shift beyond the near-infrared (NIR) region for TPE-F₄-TCNQ. Based on TD-DFT calculations, it was shown that the ICT character shown by the compounds exclusively originated from the clicked moieties independently of the nature of the central molecular platform. Photothermal (PT) studies conducted on both TPE-TCNQ and TPE-F4-TCNQ in the solid state revealed excellent properties, especially for TPE-F4-TCNQ. These results indicated that CA-RE reaction of TCNQ or F₄-TCNQ with donor-substituted are promising candidates for PT applications.

Combined Monopolar Radiofrequency and Targeted Pressure Energy for the Treatment and Improvement of Cellulite Appearance on Multiple Body Parts

Background

With many treatments available for managing cellulite, non-invasive procedures are increasingly sought after. Radiofrequency (RF) and targeted pressure energy (TPE) are new techniques developed to counter aesthetic signs of aging. The combination of RF and TPE for cellulite thus requires a more robust investigation.

Objective

We sought to determine the effectiveness and safety of combined/simultaneous RF and TPE for skin tightening and reducing the appearance of cellulite.

Methods

Thirty subjects aged 46.5±9.0 (31-74) years, BMI 19.8-36kg/m2 were enrolled and treated for cellulite on the hips, thighs, abdomen and arms. Each subject received four treatments, over 2 to 4 consecutive weeks. The circumference of the treated areas was measured at baseline, after the final treatment session, and at follow-up visits one month, three months and six months following treatment. The efficacy of the therapy was evaluated based on the Cellulite Severity Scale, Global Aesthetic Index Scale, and the Subject Satisfaction Questionnaire. Occurrence of side effects and adverse events was monitored, therapy comfort was analyzed.

Results

Cellulite severity improved from moderate to mild cellulite (p<0.001) in 95 percent of patients. Blinded, independent, evaluators reported aesthetic improvement in 90 percent of subjects. Significant circumference decrease in the abdomen, hips, and thighs was observed six months after treatment (p<0.01). Eighty-six percent of subjects were satisfied with improved cellulite appearance, and 82 percent of patients reported improved skin laxity. No severe side effects or adverse events occurred.

Conclusion

The simultaneous TPE+RF procedure was able to non-invasively improve cellulite appearance in the majority of subjects and may be recommended for skin tightening on various body parts.

Combination regimens containing daratumumab for initial diagnosed acquired thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and organ ischemia associated with disseminated microvascular platelet-rich thrombus. Before the introduction of plasma therapy, acute TTP was almost universally fatal, which improved survival from < 10 to 80-90%. However, patients who survived an acute attack were at high risk for recurrence and long-term morbidity. It was reported that daratumumab can eradicate persistent ADAMTS13-inhibiting autoantibodies and restore ADAMTS13 activity in two patients with relapsed immune-mediated TTP without associated adverse drug reactions. Here we report a case series of patients with initial diagnosed acquired TTP treated with combination regimens containing daratumumab. All the patients achieved clinical response after the initial treatment. Three patients achieved clinical remission, one patient relapsed and one patient suffered an exacerbation during follow-up. The two patients were retreated with glucocorticoids, plasma exchange combined with daratumumab, and clinical remission was achieved again. Combination of daratumumab in the treatment of initial diagnosed acquired thrombotic thrombocytopenic purpura can rapidly restore ADAMST13 activity and turn negative for ADAMST13 inhibitors, resulting in long-term remission in patients.

Evaluation of Effective Crosslinking Density for Pseudo-Semi Interpenetrating Polymer Networks Based on Polyether Glycols Mixture by Dynamic Mechanical Analysis

Pseudo-semi interpenetrating polymer networks (pseudo-semi IPNs) are a special example of topological isomerism in macromolecules, which have attracted significant attention in recent years with a high potential in a variety of engineering applications of polymeric materials. In this article, pseudo-semi IPNs were synthetized by sequential polymerization of thermoplastic polymers (TPEs) in the presence of thermosetting elastomer (TSEs) with contents of 10, 20, 30, 40 and 50 wt.% in a vacuum oven at 60 °C for about 72 h. In addition, this article describes a method for researching the elastic modulus, effective crosslinking density and physical crosslinking density of TSEs and pseudo-semi IPNs. The inherent interactions and entanglements of pseudo-semi IPNs were discussed by analyzing the changes in elastic modulus and effective crosslinking density at different temperatures. The results show that after the TPE was added to the TSE matrix as a plastic-reinforced material, the ductility increased from 89.6% to 491%, the effective crosslinking density was increased by 100% at high temperatures and the strength of the material matrix was significantly improved. Two physical events take place in our pseudo-semi IPNs as result of energy dissipation and polymeric chains mobility.

Prognosis of hyperviscosity syndrome in newly diagnosed multiple myeloma in modern-era therapy: A real-life study

Hyperviscosity syndrome (HVS) is a rare complication of newly diagnosed multiple myeloma (NDMM) related to high tumour burden. Studies about the prognosis of HVS in modern-era therapy for NDMM are missing. We investigated a retrospective cohort study of NDMM with HVS between 2011-2021. Thirty-nine NDMM patients with HVS were included. HVS presentation was heterogeneous, with asymptomatic, mild, and neurological forms in 23%, 59%, and 18% of cases, respectively. No thrombosis or major bleeding was observed. Therapeutic plasma exchanges were used in 92% of patients, which were effective and well tolerated. No rebound effect was observed. All patients except one had at least one CRAB criterion. Most of the patients received bortezomib and high-dose steroids (95%) associated with an immunomodulatory drug (43%) or alkylating agents (42%). HVS in NDMM patients had dismal overall survival matched to multiple myeloma patient controls (without HVS) in our center (median: 3.6 vs. 7.7 years, p=0.01), as confirmed by multivariate analysis. Early deaths (in the first two months) occurred in 21% of older patients (>65 years). HVS in NDMM patients is a rare but life-threatening complication associated with high lethality in older patients and be a potential dismal prognosis factor in the modern treatment era.

Outcomes of 434 dogs with non-steroidal anti-inflammatory drug toxicosis treated with fluid therapy, lipid emulsion, or therapeutic plasma exchange

BACKGROUND

Traditional management of non-steroidal anti-inflammatory drug (NSAID) intoxication includes gastrointestinal decontamination, intravenous administration of fluids (IVF), and gastroprotection. Intravenous administration of lipid emulsion (ILE) and therapeutic plasma exchange (TPE) are popular novel therapeutic strategies.

HYPOTHESIS

Compare outcomes of dogs treated with IVF, ILE, and TPE for NSAID intoxications and evaluate outcome predictors for drug subgroups.

ANIMALS

Four hundred thirty-four dogs with NSAID intoxications (2015-2020).

METHODS

Multicenter retrospective study of ibuprofen, carprofen, and naproxen intoxication. An ordinal outcome was defined as mild gastrointestinal, moderate kidney, or signs of severe central nervous system disease.

RESULTS

Signs of neurological disease were overrepresented and acute kidney injury underrepresented in the TPE group among dogs exposed to kidney- or CNS-toxic doses (P = .05), though all TPE dogs with signs of neurological disease had evidence of neurotoxicity at presentation. Dogs treated with IVF had a higher maximal creatinine concentration (median, 1.1 mg/dL; range, 0.4-8.44 mg/dL) compared with IVF + ILE (median, 0.9 mg/dL; range, 0.4-6.2 mg/dL; P = .01). Increased maximum time to presentation (P < .001), higher baseline creatinine (P < .001) and PCV (P = .007), and absence of induced emesis (P < .001) were associated with greater clinical severity. Ibuprofen toxicosis was associated with more severe clinical signs compared with carprofen (P = .03). Overall survival rate was 99%.

CONCLUSIONS AND CLINICAL IMPORTANCE

NSAID toxicosis generally carries an excellent prognosis in dogs. Despite similar outcomes of lower incidence of AKI in the TPE group, and slightly lower maximal creatinine concentration in dogs treated with ILE vs IVF alone, ILE and TPE should be considered in the management of severe NSAID toxicosis.

Fused Filament Fabrication of Bio-Based Polyether-Block-Amide Polymers (PEBAX) and Their Related Properties

This paper describes the application of poly(ether-block-amide) polymers, so-called Pebax, in fused filament fabrication (FFF). Pebax^® is a thermoplastic elastomer (TPE), a copolymer based on rigid polyamide and soft polyether blocks. By variation of the blocks, unique properties such as soft or rigid behaviour are tailored without additional additives and plasticisers. Pebax^®Rnew^® polyamide blocks are bio-based and made from castor beans that allow the design of sustainable applications. In this study, two types of Pebax were selected, processing parameters were characterised, filaments were extruded and applied to FFF printing, and the final mechanical characteristics were determined. Both types were suitable for FFF processing with improved process stability due to less shear thinning and good mechanical performance. The connection strength between the grades was also described in the design context for complex parts with tailored soft or hard regions. Combining the two materials in one design is a promising concept, and the adhesion strength is close to the strength in the Z-direction of the flexible Pebax^®Rnew^®35R53 grade.

Ultra-short-term power forecast method for the wind farm based on feature selection and temporal convolution network

The random fluctuation of wind energy is so strong that the output power cannot be predicted in time and accurately, which will influence the safety and stability of the power system. By analyzing the output power and meteorological data, the ultra-short-term power forecast method of the wind farm has been studied in this paper. Firstly, all the feature data are preprocessed and part of them with stronger correlation with the output power are obtained according to the eXtreme Gradient Boosting (XGBoost) algorithm. Then, with the reconstructed datasets and the Tree-structured Parzen Estimator (TPE) algorithm, the optimal temporal convolution network (TCN) is achieved to forecast the output power. Finally, with respect to a certain wind farm in China, ablation study and comparative experiments are conducted respectively. The ablation experiment results show that by adding the feature selection procedure into all the models, the indicators RMSE and MAE are obviously reduced as well as the running time of the model. Among them, our proposed method based on XGBoost and TCN performs best, which provides a new prospect for investigating the ultra-short-term wind power forecast problem.

The association between QTc, QTd, TPE, and fragmented QRS before and after PPCI with hospital mortality in STEMI patients

INTRODUCTION

ST-elevation myocardial infarction (STEMI) is known to be associated with significant arrhythmia and consequent mortality. QT prolongation is a risk factor for arrhythmia in STEMI patients who underwent primary percutaneous coronary intervention (PPCI). The aim of this investigation was to evaluate the association of corrected QT interval (QTc), QT dispersion (QTd), T-wave peak to end (TPE), and fragmented QRS with mortality in these patients.

METHODS

Eligible patients with the characteristic symptoms of STEMI who underwent PPCI were included. QTc, QTd, TPE, and fragmented QRS were measured before and after the PPCI. These predictors were compared between patients who died during hospitalization and discharged patients.

RESULTS

After coronary angiography, 10 patients (4%) died during the hospitalization after PPCI. Comparing the non-survivers and discharged patients in terms of arrhythmia predictors showed that the mean QT dispersion and TPE before intervention were significantly higher in the non-survivors. Also, the number of patients who experienced fragmented QRS both before and after the intervention was significantly higher in the non-survivors.

CONCLUSION

These data suggested that evaluating such arrhythmia predictors, especially before PPCI, could be used as a predictor of mortality in STEMI patients who underwent PPCI.

Outcomes of nonsteroidal anti-inflammatory drug toxicosis treated with therapeutic plasma exchange in 62 dogs

BACKGROUND

Therapeutic plasma exchange (TPE) is gaining popularity for the management of nonsteroidal anti-inflammatory drug (NSAID) overdose in dogs.

HYPOTHESIS/OBJECTIVES

Describe a population of dogs treated with TPE for NSAID overdose.

ANIMALS

Sixty-two dogs with NSAID overdose treated with TPE.

METHODS

Multicenter retrospective study of dogs treated with TPE for ibuprofen, carprofen, or naproxen overdose.

RESULTS

The median dose of ibuprofen, carprofen or naproxen ingested was 533 mg/kg (range, 36-4857 mg/kg), 217 mg/kg (range, 88-625 mg/kg) and 138 mg/kg (range, 26-3000 mg/kg), respectively. Based on previously established toxic ranges for each NSAID, 2 (3.2%), 14 (22.6%), and 46 (74.2%) dogs ingested a gastrointestinal, renal, and neurological toxic dose, respectively. The median time between ingestion and presentation was 4 hours (range, 1-20 hours). The median number of plasma volumes processed was 1.6 (range, 0.4-2.2). The median TPE session duration was 2 hours (range, 1-4.5 hours). Circuit clotting developed during 8 (12.9%) sessions. Patient adverse events reported during 21 (33.8%) sessions consisted of urticaria (12.9%), asymptomatic hypocalcemia (9.6%), and hypotension (9.6%). The median duration of hospitalization was 2.25 days (range, 1-11 days). Sixty-one (98.4%) dogs survived to discharge, and none were rehospitalized. Thirty-one (91.1%) of the 34 dogs with at least 1 follow-up visit were not azotemic at the time of reevaluation.

CONCLUSIONS AND CLINICAL IMPORTANCE

This population of dogs managed with TPE had excellent outcomes, even in cases of high NSAID dose ingestion. When TPE is available and the time frame is appropriate, this extracorporeal modality should be considered for the management of NSAID overdose.

The Use of Therapeutic Plasma Exchange in the Treatment of a Pregnant Woman with COVID-19 Induced Acute Respiratory Distress Syndrome

A 27-year-old woman at 17 weeks gestation was admitted to the intensive care unit (ICU) with a history of fever, dyspnea, and dry cough for 3 days. She was diagnosed with coronavirus disease 2019 (COVID-19) based on her nasopharyngeal swab polymerase chain reaction (PCR) that was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the ICU, the patient developed acute respiratory distress syndrome (ARDS) and increased levels of inflammatory markers. She was then intubated for mechanical ventilation and had a treatment for critical COVID-19 illness during pregnancy. She also received three cycles on alternating days of therapeutic plasma exchange (TPE) since she was failing to respond to conventional medical treatment. During hospitalization, the patient’s fetus was closely monitored by repetitive ultrasound. After 27 days of hospitalization and 10 days of mechanical ventilation weaning, the patient’s respiratory condition improved and her inflammatory biomarkers normalized. She was discharged from the hospital with an apparently healthy 20th week fetus. This case report highlights the role of TPE for treatment of ARDS due to cytokine storm in pregnant women with severe COVID-19 infection. This case emphasizes that careful evaluation of clinical and biological progression of the patient’s status is very important and when conventional therapies are failing, alternative therapies such as TPE should be considered.

Therapeutic plasma exchange in the intensive care unit and with the critically ill, a focus on clinical nursing considerations

Therapeutic plasma exchange (TPE) is a blood purification technique removing antibodies and plasma proteins to modulate disease and promote recovery. The procedure has different methods, using a membrane or plasma separator with many elements similar to continuous renal replacement therapy (CCRT) in the Intensive Care Unit (ICU). These nursing knowledge and skill sets apply where ICU nurses are providing TPE with increasing need. However, different care models are also in place where TPE is the responsibility of apheresis and nephrology teams visiting the ICU. The plasma replacement volume and prescribing is aligned with published guidelines but is variable when critical illness overlays the primary indication for TPE. There are some important considerations for TPE with respect to anticoagulation, machine settings, prescribing, and associated nursing management. TPE can be performed concurrent with CRRT in acute situations using Y‐piece and valve connectors and is a new and recent advanced blood purification for the ICU.

Therapeutic plasma exchange for peripheral neuropathy associated with trisulfated heparan disaccharide IgM antibodies: A case series of 17 patients

BACKGROUND

Small fiber neuropathy (SFN) can be associated with autoantibodies, including those of IgM class with specificity for the trisulfated heparan disaccharide (TS-HDS) antigen. We hypothesized that, as an IgM autoantibody-mediated disorder, TS-HDS-associated SFN symptoms may be reduced with therapeutic plasma exchange (TPE).

STUDY METHODS

This was an observational analysis of all patients referred for TPE from 2018 to 2020 following laboratory confirmation of SFN with TS-HDS autoantibodies; a loading course of 3 to 5 procedures over 2 weeks was completed, with some patients returning for monthly procedures. The following data were collected: demographics, symptoms and duration, TS-HDS levels, skin biopsy results, reported responses to TPE, and TPE-associated adverse events.

RESULTS

Of the 17 subjects, 12 (71%) were female and the mean age was 57.5 years (range 27-94). The most common reported symptom was lower extremity paresthesia (88% of subjects). The mean number of TPE procedures completed per subject was 9 (range 3-18), with 71% (12/17) reporting symptomatic improvement or slowed disease progression. About 15% of procedures were associated with an adverse event, with vasovagal reactions being the most common; 53% of patients had at least one adverse event.

CONCLUSIONS

Given a reported symptomatic response rate of more than 70%, TPE may be a treatment option for individuals with autoimmune-mediated SFN associated with increased titers of TS-HDS IgM autoantibodies. Since TPE-associated adverse events appear common in this population, close monitoring during procedures is warranted.

A case of Bickerstaff encephalitis with overlapping Gullian Barre syndrome in a pediatric patient treated with therapeutic plasma exchange

Bickerstaff brain stem encephalitis (BBE) is a rare brainstem disorder characterized by acute onset of ophthalmoplegia, ataxia, and altered consciousness. Guillain Barre syndrome (GBS), Miller Fischer syndrome and BBE share certain similarities such as the presence of anti-ganglioside antibodies. The use of Therapeutic Plasma Exchange (TPE) has been reserved for severe to fulminant cases of BBE mostly as an 'off label' use. The role of TPE in the overlapping syndrome of BBE and GBS has not been explored much, especially in the paediatric population. Herein, we describe a case of 2-year-old male who presented with features of BBE and later evolved to an overlapping syndrome with BBE and GBS. A multi-disciplinary team managed the patient and TPE was initiated as a part of the treatment plan. Five cycles of TPE were done from day 24 after which the patient improved. In our case, TPE was used as rescue therapy in patients with BBE overlapping with GBS. The effectiveness of TPE can be further explored as a modality in such disorders.

Modeling Treatment Strategies to Inform Yaws Eradication

Yaws is a neglected tropical disease targeted for eradication by 2030. To achieve eradication, finding and treating asymptomatic infections as well as clinical cases is crucial. The proposed plan, the Morges strategy, involves rounds of total community treatment (i.e., treating the whole population) and total targeted treatment (TTT) (i.e., treating clinical cases and contacts). However, modeling and empirical work suggests asymptomatic infections often are not found in the same households as clinical cases, reducing the utility of household-based contact tracing for a TTT strategy. We use a model fitted to data from the Solomon Islands to predict the likelihood of elimination of transmission under different intervention schemes and levels of systematic nontreatment resulting from the intervention. Our results indicate that implementing additional treatment rounds through total community treatment is more effective than conducting additional rounds of treatment of at-risk persons through TTT.

Studies of the Sulfonated Hydrogenated Styrene-Isoprene-Styrene Block Copolymer and Its Surface Properties, Cytotoxicity, and Platelet-Contacting Characteristics

Styrenic thermoplastic elastomers (TPEs) consist of styrenic blocks. They are connected with other soft segments by a covalent linkage and are widely used in human life. However, in biomedical applications, TPEs need to be chemically hydrogenated in advance to enhance their properties such as strong UV/ozone resistance and thermal-oxidative stability. In this study, films composed of sulfonated hydrogenated TPEs were evaluated. Hydrogenated tert-butyl styrene–styrene–isoprene block copolymers were synthesized and selectively sulfonated to different degrees by reaction with acetyl sulfate. By controlling the ratio of the hydrogenated tert-butyl styrene–styrene–isoprene block copolymer and acetyl sulfate, sulfonated films were optimized to demonstrate sufficient mechanical integrity in water as well as good biocompatibility. The thermal plastic sulfonated films were found to be free of cytotoxicity and platelet-compatible and could be potential candidates in biomedical film applications such as wound dressings.

Use of therapeutic plasma exchange for pediatric neurological diseases

Therapeutic plasma exchange is used to treat neurological diseases in the pediatric population. Since its first use in pediatric patients with hepatic coma in the form of manual whole blood exchange, therapeutic plasma exchange has been increasingly used to treat these disorders of the nervous system. This expansion is a result of improved techniques and apheresis instruments suitable for small children, as well as the recognition of its applicability to many diseases in the pediatric population. This review provides a historical overview of the use of therapeutic apheresis in children and highlights the most common applications for therapeutic plasma exchange to treat neurological disorders in children.

Mathematical modeling of the impact of recirculation on exchange kinetics in tandem extracorporeal membrane oxygenation and therapeutic plasma exchange

Vascular access connection configurations during tandem extracorporeal membrane oxygenation (ECMO) and therapeutic plasma exchange (TPE) may impact exchange kinetics. In these tandem procedures, typically the TPE inlet line is proximal to the TPE return line with respect to blood flow in the ECMO device, maximizing the opportunity for replacement fluid homogenization within the ECMO circuit. However, if TPE inlet and return line connections are switched, recirculation-a phenomenon in which replacement fluid leaving the TPE return line is prematurely drawn into the TPE inlet line prior to satisfactory homogenization within the ECMO circuit-will occur. Such recirculation could diminish TPE efficacy in patients on ECMO and mitigate therapeutic benefits. Using a mathematical model of recirculation in tandem ECMO and TPE, we demonstrate that the predicted impact of recirculation is negligible and vascular access connection positioning does not appear to be a point of clinical concern with regard to TPE kinetics.

Recycling and Reprocessing of Thermoplastic Polyurethane Materials towards Nonwoven Processing

Thermoplastic Polyurethane (TPU) is a unique tailorable material due to the interactions of hard and soft segments within the block-copolymer chain. Therefore, various products can be created out of this material. A general trend towards a circular economy with regards to sustainability in combination with TPU being comparably expensive is of high interest to recycle production as well as post-consumer wastes. A systematic study investigating the property changes of TPU is provided, focusing on two major aspects. The first aspect focuses on characterizing the change of basic raw material properties through recycling. Gel permeation chromatography (GPC) and processing load during extrusion indicate a decrease in molar mass and consequently viscosity with an increasing number of recycling cycles. This leads to a change in morphology at lower molar mass, characterized by differential scanning calorimetry (DSC) and visualized by atomic force microscope (AFM). The change in molar mass and morphology with increasing number of recycling cycles has an impact on the material performance under tensile stress. The second aspect describes processing of the recycled TPU to nonwoven fabrics utilizing melt blowing, which are evaluated with respect to relevant mechanical properties and related to molecular characteristics. The molar mass turns out to be the governing factor regarding mechanical performance and processing conditions for melt blown products.

Supracapsular phacoemulsification: Description of the "Garde à vous" technique and comparative clinical results

Phacoemulsification techniques can be divided into 2 categories: endocapsular and supracapsular techniques. Supracapsular techniques involve phacoemulsification of the nucleus outside and above the capsular plane. The "Garde-à-vous" technique described in this manuscript is a modified and improved version of the supracapsular procedure with up-to-date technology in micro-coaxial surgery. It maintains the known advantages of supracapsular techniques such as faster surgical times and lower rates of capsular tears and brings a standardized technique with well-defined surgical steps in order to achieve tilting of the nucleus in a vertical or oblique position in almost 100% of cases by performing a double-wave hydro-dissection. The authors also give the results of a non-randomized prospective study, comparing the "Garde-à-vous" technique and the standard "cracking" technique in 2856 cases. The results show that for the "Garde-à-vous group", the patients were significantly younger (P<0.001), the power of ultrasound used was greater (P<0.001) for lower UST (ultrasound time or average phacoemulsification time APT) and EPT (effective phacoemulsication time) (P<0.001), the duration of the procedure was shorter (P<0.001), patient discomfort was less (P<0.001), and the power of the implants used was lower (P<0.01). With regard to the gender of the patients, the percentage of topical anesthesia and the rate of intraoperative complications (posterior capsular rupture), there was no statistically significant difference.

Bring It to an End: Does Telomeres Size Matter?

Telomeres are unique nucleoprotein structures. Found at the edge of each chromosome, their main purpose is to mask DNA ends from the DNA-repair machinery by formation of protective loops. Through life and cell divisions, telomeres shorten and bring cells closer to either cell proliferation crisis or senescence. Beyond this mitotic clock role attributed to the need for telomere to be maintained over a critical length, the very tip of our DNA has been shown to impact transcription by position effect. TPE and a long-reach counterpart, TPE-OLD, are mechanisms recently described in human biology. Still in infancy, the mechanism of action of these processes and their respective genome wide impact remain to be resolved. In this review, we will discuss recent findings on telomere dynamics, TPE, TPE-OLD, and lessons learnt from model organisms.

Therapeutic plasma exchange for thrombotic thrombocytopenic purpura with refractory thrombocytopenia

Thrombotic thrombocytopenic purpura (TTP) is an acute, life-threatening illness with disseminated platelet-rich thromboses of small vessels that variably presents with the classic clinical "pentad" of microangiopathic hemolytic anemia, thrombocytopenia, fever, altered mental status, and acute kidney injury. Most cases are caused by an acquired autoantibody to ADAMTS13, a metalloproteinase that cleaves large von Willebrand Factor (vWF) multimers. The mainstay of treatment is daily therapeutic plasma exchange (TPE), sometimes with adjunctive pharmacologic immunosuppression. TPE is generally continued until the platelet count is greater than 150 × 10³ /µL and the lactate dehydrogenase is near normal for 2-3 consecutive days. Unfortunately, there is no clear guidance for when thrombocytopenia is refractory for a prolonged period of time. The following case describes such a scenario in which consecutive ADAMTS13 activity and inhibitor levels were used to guide the decision to stop treatment with TPE in a patient who failed to recover their platelet count.

The use of therapeutic plasma exchange to reduce serum bilirubin in a dog with kernicterus

OBJECTIVE

To describe the use of a manual method of therapeutic plasma exchange to reduce total serum bilirubin, manage kernicterus, and halt progression of neurological dysfunction in a dog with immune-mediated hemolytic anemia (IMHA).

CASE SUMMARY

A 5-year-old male neutered Lhasa Apso diagnosed with IMHA developed acute onset neurologic signs consistent with kernicterus. Manual therapeutic plasma exchange was performed in an attempt to reduce total serum bilirubin. The initial exchange was performed at a lower plasma exchange volume due to the dog's critical status and the dog's clinical signs progressed. More aggressive plasma exchange was performed that resulted in a reduction in total serum bilirubin and no further progression of neurologic signs. The dog was euthanized due to suspicion of permanent neurologic changes and need for further blood transfusions. Histopathology postmortem confirmed a diagnosis of kernicterus.

NEW OR UNIQUE INFORMATION PROVIDED

Kernicterus secondary to hyperbilirubinemia is well described in people, but has rarely been reported in dogs. Therapeutic plasma exchange has been used for decades in people to rapidly decrease serum bilirubin when hyperbilirubinemia progresses to neurologic signs, but to the authors' knowledge this has not been described in a dog.

Adrift in the world of therapeutic apheresis: One center's experience in using arterio-venous fistulas during apheresis procedures

Therapeutic plasma exchange (TPE) is often an isolated specialty with very little research, especially in regard to the mode of access. This lack of information drove this attempt at reviewing the use of arterio-venous fistulas (AVF) in TPE, and specifically the issue of monitoring the accesses patency. Using a Transonic®, we attempted to obtain a reading, using the Spectra Optia™ on a patient's access. Unfortunately, due to the limitations of the equipment, we were unable to get a reading. Our conclusion is that we will have to monitor using other approaches, such as physical assessment and ultrasound.

CDC28 phosphorylates Cac1p and regulates the association of chromatin assembly factor I with chromatin

Chromatin Assembly Factor I (CAF-I) plays a key role in the replication-coupled assembly of nucleosomes. It is expected that its function is linked to the regulation of the cell cycle, but little detail is available. Current models suggest that CAF-I is recruited to replication forks and to chromatin via an interaction between its Cac1p subunit and the replication sliding clamp, PCNA, and that this interaction is stimulated by the kinase CDC7. Here we show that another kinase, CDC28, phosphorylates Cac1p on serines 94 and 515 in early S phase and regulates its association with chromatin, but not its association with PCNA. Mutations in the Cac1p-phosphorylation sites of CDC28 but not of CDC7 substantially reduce the in vivo phosphorylation of Cac1p. However, mutations in the putative CDC7 target sites on Cac1p reduce its stability. The association of CAF-I with chromatin is impaired in a cdc28-1 mutant and to a lesser extent in a cdc7-1 mutant. In addition, mutations in the Cac1p-phosphorylation sites by both CDC28 and CDC7 reduce gene silencing at the telomeres. We propose that this phosphorylation represents a regulatory step in the recruitment of CAF-I to chromatin in early S phase that is distinct from the association of CAF-I with PCNA. Hence, we implicate CDC28 in the regulation of chromatin reassembly during DNA replication. These findings provide novel mechanistic insights on the links between cell-cycle regulation, DNA replication and chromatin reassembly.

Does corticosteroid treatment cause prolonged recovery and increased total bilirubin level in severe ADAMTS-13-deficient TTP patient?

A 41-year-old female patient complaining of fatigue, headache, mild confusion, and rush on her lower extremities was admitted to our emergency department. Laboratory tests revealed that he had anemia, thrombocytopenia, and increased levels of indirect bilirubin and lactic dehydrogenase (LDH) in blood tests. Direct and indirect Coombs tests were negative, and fragmented erythrocytes were observed in peripheral blood smears. The patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). The best supportive care was provided. Therapeutic plasma exchange (TPE) and 1 mg/kg methylprednisolone treatments were administered. On the 10th day of treatment, LDH level and fragmented red blood cells in peripheral blood smear were decreased, but his direct and indirect bilirubin levels increased despite the fact that he was treated with 1 mg/kg methylprednisolone and TPE. The patient had severe ADAMTS-13 deficiency. After discontinued steroids treatment, his bilirubin level normalized within 4 days. On the 4th day after bilirubin level normalized, vincristine treatment was administered. TPE was also continued. There was no consensus about the optimal schedule for discontinuing plasmapheresis therapy, and also we observed total bilirubin level improvement with discontinued corticosteroid treatment. In this case, corticosteroid treatment was linked with the increase of total bilirubin level in severe ADAMTS-13-deficient TTP patient.

Overcoming technical challenges when treating atypical hemolytic uremic syndrome with therapeutic plasma exchange

Atypical hemolytic uremic syndrome (aHUS) is a very rare, life-threatening, progressive disease that frequently has a genetic component and in most cases is triggered by an uncontrolled activation of the complement system. Successful treatment of aHUS with plasma infusions and therapeutic plasma exchange (TPE) is well reported. TPE has been the treatment of choice in most adult patients with aHUS. However, due to severe hemolysis, which is common among aHUS patients, there are some technical challenges that can affect TPE treatment such as the continuous activation of the blood leak alarm due to hemolysis. Our experience shows that such patients can be managed better on a centrifuge based TPE machine compared to a membrane based TPE machine.

Effete, an E2 ubiquitin-conjugating enzyme with multiple roles in Drosophila development and chromatin organization

The Drosophila effete gene encodes an extremely conserved class I E2 ubiquitin-conjugating enzyme. Growing evidence indicates that Eff is involved in many cellular processes including eye development, maintenance of female germline stem cells, and regulation of apoptosis. Eff is also a major component of Drosophila chromatin and it is particularly enriched in chromatin with repressive properties. In addition, Eff is required for telomere protection and to prevent telomere fusion. Consistent with its multiple roles in chromatin maintenance, Eff is also one of the rare factors that modulate both telomere-induced and heterochromatin-induced position effect variegation.

Somatostatin receptors: from signaling to clinical practice

Somatostatin is a peptide with a potent and broad antisecretory action, which makes it an invaluable drug target for the pharmacological management of pituitary adenomas and neuroendocrine tumors. Somatostatin receptors (SSTR1, 2A and B, 3, 4 and 5) belong to the G protein coupled receptor family and have a wide expression pattern in both normal tissues and solid tumors. Investigating the function of each SSTR in several tumor types has provided a wealth of information about the common but also distinct signaling cascades that suppress tumor cell proliferation, survival and angiogenesis. This provided the rationale for developing multireceptor-targeted somatostatin analogs and combination therapies with signaling-targeted agents such as inhibitors of the mammalian (or mechanistic) target of rapamycin (mTOR). The ability of SSTR to internalize and the development of rabiolabeled somatostatin analogs have improved the diagnosis and treatment of neuroendocrine tumors.

Exacerbation of experimental autoimmune encephalomyelitis by passive transfer of IgG antibodies from a multiple sclerosis patient responsive to immunoadsorption

The pathogenic role of antibodies in multiple sclerosis (MS) is still controversial. We transferred to mice with experimental autoimmune encephalomyelitis (EAE), animal model of MS, IgG antibodies purified from a MS patient presenting a dramatic clinical improvement during relapse after selective IgG removal with immunoadsorption. Passive transfer of patient's IgG exacerbated motor paralysis and increased mouse central nervous system (CNS) inflammation and demyelination. Binding of patient's IgG was demonstrated in mouse CNS, with a diffuse staining of white matter oligodendrocytes. These data support a growing body of evidence that antibodies can play an important role in the pathobiology of MS.